A postsurgical client has been receiving morphine by patient-controlled analgesia for 2 days. What action by the nurse best addresses potential adverse effects?
administering a stool softener as prescribed
auscultating the client's lung for adventitious sounds
encouraging active range of motion exercises
applying calf compressors as prescribed
The Correct Answer is A
A. Administering a stool softener is essential as opioids like morphine commonly cause constipation, and this proactive measure helps mitigate that adverse effect.
B. While auscultating the lungs is important to monitor respiratory function, it does not specifically address a common adverse effect of morphine.
C. Encouraging active range of motion exercises can help prevent complications from immobility but does not directly address the most common adverse effect of morphine.
D. Applying calf compressors can help prevent deep vein thrombosis, but it is not the most effective action for addressing the specific adverse effects of morphine use.
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Correct Answer is B
Explanation
A. Increasing fluid intake may not alleviate the cramping and diarrhea, which are common side effects of magnesium citrate.
B. Abdominal cramping and diarrhea are expected side effects of magnesium citrate, and the patient can continue the medication unless symptoms become severe.
C. Discontinuing the medication should not be recommended unless the side effects are intolerable or the patient experiences severe reactions.
D. Switching to a different type of laxative is unnecessary unless the patient has contraindications to magnesium citrate or develops severe side effects.
Correct Answer is B
Explanation
A. Performing a blood sugar analysis is important, but the immediate symptoms indicate hypoglycemia, and rapid treatment is necessary before confirming blood sugar levels.
B. Having the client drink a glass of orange juice provides a quick source of glucose to counteract hypoglycemia, which is the most appropriate initial response to address the client's symptoms.
C. Administering 1 ampule of 50% dextrose intravenously is an appropriate intervention for severe hypoglycemia but is not the initial step for a client who can still take oral carbohydrates.
D. Administering insulin would worsen the client's condition by lowering blood sugar levels further, which is not indicated in this scenario.